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DEPARTMENT DECISION APPLICATION FOR HVAC PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR 6a
BUILDING DEPARTMENT
PR 1540 SULLIVAN AVENUE Bldg.Permit#
ff/(,Z 644-2511 ext. 230
Date Building Inspector ;
Application must be printed or typed
FEE SCHEDULE Location of Job:
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$0-$1,000=$15.00 Street No. Stre Lot No.
Over$1,000= !
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT -=t-s-a1 e ck Qrm filC
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APPLICANT ADDRESS
S. �. ► C
APPLICANT PHONE#
W N S OWNER U�2.0 7Ci res) U O Yl S
�4< OWNER ADDRESS C�-t c
OWNER PHONE U1
O
C ESTIMATED COST$ o L o
1
IS THIS A CONTRACT COST? c-�tes No
FEE ENCLOSED$ S v
TYPE OF JOB:
�SOR.Cps
New Installation
Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR HVAC PERMIT (Continued from reverse side)
TYPE F YSTEM: TYPE QF BUILDING:
❑
HEATING RESIDENTIAL
A/C ❑COMMERCIAL
❑VENTILATION ❑INDUSTRIAL
HEATING
❑ STEAM LOW PRESSURE LIMIT LBS. HIGH PRESSURE LIMIT LBS.
❑HYDRONIC ❑WARM AIR ❑UNIT RADIANT HEATER
EXISTING RADIATION ADDITIONAL RADIATION TOTAL RADIATION
DESIGN TEMP. OUTSIDE °F INSIDE OF DIFFERENCE OF
TOTAL HEAT LOSS(BTUH) OF(HEAT LOSS SHEET MUST ACCOMPANY
APPLICATION)
DESCRIBE ALL HEATING EQUIPMENT(INCLUDING MAKE&MODEL NO.)
GROSS HEATING CAPACITY(INPUT-BTUH) NET RATING(OUTPUT-BTUH)
TYPE OF FUEL
3�AS:=67
ILOIL TANK LOCATION: INSIDE❑OUTSIDE CAPACITY
LPG TANK CAPA ITY ELECTRIC-KW
AIR CONDITIONING
DESIGN TEMP.OUTSIDE OF INSIDE OF DIFFERENCE OF
TOTAL HEAT GAIN(BTUH) (HEAT GAIN SHEET MUST ACCOMPANY APPLICATION)
DESCRIBE ALL COOLING EQUIPMENT(INCLUDING MAKE&MODEL NO.)
TONNAGE COOLING CAPACITY(BTUH)
VENTILATION
DESCRIBE ALL AIR HANDLING EQUIPMENT(INCLUDING KITCHEN EXHAUST EQUIPMENT)
TOTAL SIZE OF SYSTEM(CFM) FRESH AIR INTAKE(CFM)
(PLANS MUST ACCOMPANY APPLICATION)
FURTHER DESCRIPTION OF WORK
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
5 O,� 2`-1 S- -2) Q-7-
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE U ~Z._